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  1. 1. PTA 200 Modalities and Procedures in Physical Therapy Hydrotherapy
  2. 2. Definition of Hydrotherapy <ul><li>Application of water, internally or externally, for the treatment of physical or psychological dysfunction. </li></ul>
  3. 3. Types of Hydrotherapy <ul><li>Immersion </li></ul><ul><li>Non-Immersion </li></ul>
  4. 4. Primary Use of Hydrotherapy <ul><li>Treatment of Wounds </li></ul><ul><li>Enhanced Environment for exercise </li></ul><ul><li>Pain </li></ul><ul><li>Edema </li></ul><ul><li>Health maintenance /disease prevention </li></ul>
  5. 5. Physical Properties of Water <ul><li>High Specific Heat & Thermal Conductivity </li></ul><ul><li>Transfers heat by Conduction and Convection </li></ul><ul><ul><li>Can be used as superficial heating and cooling agent </li></ul></ul>
  6. 6. Physical Properties of Water <ul><li>Specific Heat 4 times that of air </li></ul><ul><ul><li>Water retains 4x as much thermal energy as an equivalent mass of air </li></ul></ul><ul><li>Thermal Conductivity 25 x air </li></ul><ul><ul><li>Water transfers thermal energy 25 x more rapidly than air ( at the same temperature ) </li></ul></ul>
  7. 7. Physical Properties of Water <ul><li>Transfers heat rapidly, efficiently </li></ul><ul><li>Advantage of exercising patient in pool colder than patient’s body temperature. </li></ul><ul><ul><li>Immersion dissipates heat generated by exertion </li></ul></ul>
  8. 8. Physical Properties of Water <ul><li>Water that is stationary transfers heat by Conduction . </li></ul><ul><li>Moving water transfers heat by Conduction and Convection . </li></ul><ul><ul><li>Heating (WP) accelerated with increased agitation of water. </li></ul></ul><ul><ul><li>Cooling (swimming) accelerated as patient moves more quickly through water. </li></ul></ul>
  9. 9. Physical Properties of Water <ul><li>Buoyancy </li></ul><ul><ul><li>A force experienced as an upward thrust on the body in the opposite direction to the force of gravity </li></ul></ul><ul><li>Archimedes Principle </li></ul><ul><ul><li>When a body is entirely or partially immersed in a fluid at rest.. </li></ul></ul><ul><ul><ul><li>it experiences an upward thrust equal to weight of fluid it displaces. </li></ul></ul></ul><ul><ul><ul><ul><li>Principle used for volumetric measurements </li></ul></ul></ul></ul>
  10. 10. Archimedes Principle <ul><li>Amount of fluid depends on density of body relative to density of fluid. </li></ul><ul><ul><li>If density of body less than density of fluid, it will displace a smaller volume of fluid (Floats) </li></ul></ul><ul><ul><ul><li>Opposite also true </li></ul></ul></ul><ul><ul><li>If density of body further decreased ( adding salt to water or air-filled objects at rest ), </li></ul></ul><ul><ul><ul><li>Body will float higher </li></ul></ul></ul>
  11. 11. Clinical Uses of Buoyancy <ul><li>Decrease stress and compression to body tissues ( weight-bearing surfaces ) </li></ul><ul><li>Assist weak muscles </li></ul>
  12. 12. Physical Properties of Water <ul><li>Resistance </li></ul><ul><ul><li>Viscosity of water provides resistance to motion </li></ul></ul><ul><ul><li>Resistance occurs against direction of motion </li></ul></ul><ul><li>Resistance increases proportional to… </li></ul><ul><ul><li>Speed </li></ul></ul><ul><ul><li>Frontal area of body part in contact with water </li></ul></ul><ul><li>Varying resistance ( and pressure ) can be beneficial in debriding and cleansing wounds </li></ul>
  13. 13. Physical Properties of Water <ul><li>Hydrostatic Pressure </li></ul><ul><ul><li>Pressure exerted by fluid on body immersed in fluid. </li></ul></ul><ul><li>Pascal’s Law </li></ul><ul><ul><li>A fluid exerts equal pressure on all surfaces of a body at rest, at a given depth… </li></ul></ul><ul><ul><li>This pressure increases in proportion to depth of fluid </li></ul></ul>
  14. 14. Hydrostatic Pressure <ul><li>Water = 0.73 mmHg/cm of depth (22.4 mmHg/ft) </li></ul><ul><li>Patient upright </li></ul><ul><ul><li>Pressure on distal extremities > proximal extremities </li></ul></ul><ul><ul><li>Hydrostatic pressure at patient’s feet… </li></ul></ul><ul><ul><ul><li>4 ft of water = 89.6 mmHg </li></ul></ul></ul>
  15. 15. Hydrostatic Pressure <ul><li>Water can have similar effect as compression devices/ bandages </li></ul><ul><ul><li>Helpful in decreasing edema </li></ul></ul><ul><ul><li>If limb in dependent position, counteracts this effect </li></ul></ul><ul><li>Greatest effects of hydrostatic pressure occur in vertical position </li></ul><ul><ul><li>NO hydrostatic pressure effects with non-immersion hydrotherapy </li></ul></ul>
  16. 16. Physiological Effects of Hydrotherapy
  17. 17. Physiological Effects <ul><li>Cleansing </li></ul><ul><ul><li>Pressure (Force = Rate of Flow) </li></ul></ul><ul><ul><li>Dissolved antimicrobial agents, etc. ( Wounds ) </li></ul></ul><ul><li>Musculoskeletal Effects </li></ul><ul><ul><li>Decreases weight-bearing ( Arthritis ) </li></ul></ul><ul><ul><ul><li>75% immersion WB 75% </li></ul></ul></ul><ul><ul><li>Increases blood flow to muscles </li></ul></ul><ul><ul><li>Strengthening </li></ul></ul>
  18. 18. Physiological Effects <ul><li>Decreased bone density loss </li></ul><ul><li>Decreased fat loss </li></ul><ul><ul><ul><li>Compared to other forms of exercise </li></ul></ul></ul><ul><ul><li>Good for obese secondary to non-weight bearing exercise </li></ul></ul><ul><ul><ul><li>Not good for general weight loss </li></ul></ul></ul>
  19. 19. Cardiovascular Effects <ul><li>Increased venous circulation </li></ul><ul><ul><li>Secondary to hydrostatic pressure, increased venous pressure </li></ul></ul><ul><li>Increased cardiac volume </li></ul><ul><li>Increased cardiac output </li></ul><ul><ul><li>Up to 30% while upright to neck </li></ul></ul><ul><li>Decreases HR and Systolic BP ( cool water ) </li></ul><ul><ul><li>May increase in warm or hot water </li></ul></ul>
  20. 20. Respiratory Effects <ul><li>Increases work of breathing </li></ul><ul><ul><li>Due to hydrostatic pressure on lungs </li></ul></ul><ul><ul><ul><li>up to 60% </li></ul></ul></ul><ul><ul><ul><li>May need to be very careful with respiratory and/or cardiac patients </li></ul></ul></ul><ul><li>Decreases exercise-induced asthma </li></ul><ul><ul><li>High humidity </li></ul></ul>
  21. 21. Renal Effects <ul><li>Increases urine production </li></ul><ul><li>Increases sodium and potassium excretion </li></ul><ul><ul><li>May be used to patient’s advantage with hypertension, peripheral edema </li></ul></ul>
  22. 22. Psychological Effects <ul><li>Relaxing </li></ul><ul><ul><li>Warm water </li></ul></ul><ul><li>Invigorating </li></ul><ul><ul><li>Cold water </li></ul></ul>
  23. 23. Clinical Uses of Hydrotherapy
  24. 24. Superficial Heating and Cooling <ul><li>Advantages </li></ul><ul><ul><li>Even contact with skin </li></ul></ul><ul><ul><li>Does not need to be fastened </li></ul></ul><ul><ul><li>Allows movement of heat/cold </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Extremity often in dependent position </li></ul></ul>
  25. 25. Wound Care <ul><li>Cleansing properties facilitate </li></ul><ul><ul><li>Rehydration </li></ul></ul><ul><ul><li>Softening and debridement of necrotic tissue </li></ul></ul><ul><ul><li>Removal of wound debris </li></ul></ul><ul><li>Hydrostatic pressure and heat increase circulation </li></ul><ul><li>Provides moist environment to optimize healing </li></ul>
  26. 26. Immersion vs. Non-Immersion <ul><li>Non-immersion therapy becoming more popular </li></ul><ul><ul><li>Concern for increased pressure on regenerating tissues by water and turbine </li></ul></ul><ul><ul><li>Potential for infection in contaminated tank </li></ul></ul><ul><li>WP recommended for </li></ul><ul><ul><li>Extensive thick exudate </li></ul></ul><ul><ul><li>Slough or necrotic tissue </li></ul></ul><ul><ul><li>Gross purulence </li></ul></ul><ul><ul><li>Dry eschar </li></ul></ul>
  27. 27. Immersion versus Non-Immersion <ul><li>Discharge all forms of hydrotherapy when wound is clean </li></ul><ul><ul><li>Many antimicrobial products are cytoxic to normal tissue ( unless very diluted ) </li></ul></ul><ul><li>Tank and turbine must be thoroughly cleaned and disinfected </li></ul>
  28. 28. Non-Immersion Techniques <ul><li>Fluid delivered at pressure of 4-15 psi </li></ul><ul><ul><li>Below this bacteria not removed </li></ul></ul><ul><ul><li>Above this, wound trauma may occur, or bacteria driven into wound </li></ul></ul><ul><ul><li>Saline squeeze bottle, Water Pik </li></ul></ul>
  29. 29. Non-Immersion Techniques <ul><li>Recommended for </li></ul><ul><ul><li>N ecrotic, nonviable tissue or debris </li></ul></ul><ul><ul><ul><li>Continue until all removed and full granulation bed present </li></ul></ul></ul><ul><ul><ul><li>Often use both </li></ul></ul></ul><ul><li>With both types, must thoroughly dry intact skin in surrounding area </li></ul><ul><ul><li>prevents maceration </li></ul></ul>
  30. 30. Treatment of Burns <ul><li>Similar, but burns particularly painful when debrided </li></ul><ul><ul><li>Wounds sometimes less deep, sensory nerves intact </li></ul></ul><ul><li>Monitor patient closely </li></ul><ul><ul><li>often high-dose analgesics </li></ul></ul><ul><li>Hubbard Tank for large body surface area </li></ul><ul><ul><li>Chance of contamination </li></ul></ul><ul><ul><li>Greater loss of sodium ( add salt ) </li></ul></ul><ul><li>Shower (non-immersion) in early stages </li></ul><ul><li>After re-epithelialization, water for exercise </li></ul>
  31. 31. Pain Control <ul><li>Increased sensory stimulation to peripheral mechanoreceptors </li></ul><ul><ul><li>Gait Theory </li></ul></ul><ul><li>Cold water decreases inflammation </li></ul><ul><li>Decreases weight-bearing, increases “ease of movement”. </li></ul>
  32. 32. Edema Control <ul><li>Hydrostatic pressure </li></ul><ul><li>Cool water </li></ul><ul><ul><li>Vasoconstriction </li></ul></ul><ul><ul><li>Decreased vascular permeability </li></ul></ul><ul><ul><li>Hot water increases edema </li></ul></ul><ul><ul><ul><li>Increased arterial blood flow, increased vasodilation. </li></ul></ul></ul>
  33. 33. Edema Control <ul><li>Contrast Baths </li></ul><ul><ul><li>“ Trains” smooth muscles of blood vessel; vasoconstriction/vasodilation. </li></ul></ul><ul><ul><li>No research to solidly support </li></ul></ul>
  34. 34. Contraindications, Precautions and Adverse Effects
  35. 35. Contraindications, Local Immersion <ul><li>Maceration </li></ul><ul><ul><li>Increased maceration, increased size of wound </li></ul></ul><ul><li>Bleeding </li></ul><ul><ul><li>In or near the area </li></ul></ul>
  36. 36. Precautions, Local Immersion <ul><li>Impaired thermal sensation </li></ul><ul><ul><li>Check temperature of water with thermometer first </li></ul></ul><ul><li>Infection </li></ul><ul><ul><li>Universal Precautions </li></ul></ul><ul><ul><li>Clean WP </li></ul></ul><ul><li>Confusion, impaired cognition </li></ul><ul><ul><li>Use constant, direct supervision </li></ul></ul><ul><ul><li>Temperature of water near body temperature </li></ul></ul><ul><li>Recent Skin Grafts </li></ul><ul><ul><li>Direct agitator away from graft. </li></ul></ul><ul><ul><li>Neutral or mild warmth (96 - 98 0 F) </li></ul></ul>
  37. 37. Contraindications, Full Body Immersion <ul><li>Cardiac instability </li></ul><ul><ul><li>Uncontrolled hypertension or heart failure </li></ul></ul><ul><li>Infectious conditions that spread with water </li></ul><ul><ul><li>UTI’s, plantar warts, tinea pedis ( pool ) </li></ul></ul><ul><li>Bowel or bladder incontinence </li></ul><ul><ul><li>Use non-immersion techniques </li></ul></ul><ul><li>Severe epilepsy </li></ul><ul><ul><li>Increased risk of drowning </li></ul></ul><ul><li>Suicidal patients </li></ul><ul><ul><li>Increased risk of drowning </li></ul></ul>
  38. 38. Precautions, Full Body Immersion <ul><li>Confusion, Disorientation </li></ul><ul><ul><li>Keep head above water </li></ul></ul><ul><ul><li>Constant supervision </li></ul></ul><ul><ul><li>Low temperature </li></ul></ul><ul><li>After ingestion of alcohol </li></ul><ul><ul><li>Hypotensive effects </li></ul></ul><ul><ul><li>Drowning </li></ul></ul><ul><li>Patients with limited strength, endurance, balance, ROM </li></ul><ul><ul><li>Hands-on approach required </li></ul></ul>
  39. 39. Precautions, Full Body Immersion <ul><li>Patients on medications </li></ul><ul><ul><li>Physician clearance sometimes required </li></ul></ul><ul><li>Patients with fear of water </li></ul><ul><li>Patients with respiratory problems </li></ul><ul><ul><li>Watch for signs of respiratory distress, especially in hot or very warm water </li></ul></ul>
  40. 40. Precautions, Full Body Immersion <ul><li>Patients that are Pregnant </li></ul><ul><ul><li>1st trimester ( maternal hyperthermia ) </li></ul></ul><ul><ul><li>Use normal water temperature </li></ul></ul><ul><ul><li>Can be very good therapeutic intervention </li></ul></ul><ul><li>Patients with MS </li></ul><ul><ul><li>Temperature >88 0 F may cause increase fatigue, weakness. </li></ul></ul><ul><li>Patients with poor thermal regulation </li></ul><ul><ul><li>Elderly, infants </li></ul></ul>
  41. 41. Precautions, Non-Immersion Hydrotherapy <ul><li>Maceration </li></ul><ul><li>Ineffectiveness </li></ul><ul><li>Drowning </li></ul>
  42. 42. Adverse Effects of Hydrotherapy <ul><li>Burns, Fainting, Bleeding </li></ul><ul><ul><li>Check with thermometer, and gloved hand </li></ul></ul><ul><li>Hypotension </li></ul><ul><ul><li>Immersion in warm/hot water, hypertension medications </li></ul></ul><ul><li>Hyponatremia ( burns ) </li></ul><ul><li>Increased edema </li></ul><ul><ul><li>Use of hot water </li></ul></ul><ul><ul><li>Dependent positioning </li></ul></ul>
  43. 43. Application of Hydrotherapy
  44. 44. Application, General Rules <ul><li>Assess problem and set goals of treatment </li></ul><ul><li>Determine if most appropriate treatment </li></ul><ul><li>Make sure no contraindications </li></ul><ul><li>Select appropriate form of hydrotherapy </li></ul><ul><ul><li>Whirlpool </li></ul></ul><ul><ul><li>Hubbard Tank </li></ul></ul><ul><ul><li>Contrast bath </li></ul></ul><ul><ul><li>Non-immersion device </li></ul></ul><ul><ul><li>Pool </li></ul></ul><ul><li>Explain the procedure, purpose, sensations </li></ul><ul><li>Apply appropriate form of hydrotherapy </li></ul><ul><li>Assess outcome </li></ul><ul><li>Document </li></ul>
  45. 45. Selection of Hydrotherapy <ul><li>Base decision on </li></ul><ul><ul><li>Desired effects </li></ul></ul><ul><ul><li>Size of area to be treated </li></ul></ul><ul><ul><li>Allowance for safety, control of infection </li></ul></ul><ul><ul><li>Cost-effectiveness </li></ul></ul>
  46. 46. Whirlpool <ul><li>Tanks </li></ul><ul><ul><li>Low-Boy </li></ul></ul><ul><ul><li>High-Boy </li></ul></ul><ul><ul><li>Extremity </li></ul></ul><ul><ul><li>Hubbard Tank </li></ul></ul>
  47. 47. Whirlpool <ul><li>Turbine </li></ul><ul><ul><li>Agitator </li></ul></ul><ul><ul><ul><li>Adjustable height, direction, aeration. </li></ul></ul></ul><ul><ul><ul><li>Should be grounded </li></ul></ul></ul><ul><ul><ul><li>Do NOT run without water in tank. </li></ul></ul></ul>
  48. 48. Low-Boy
  49. 49. Hubbard Tank
  50. 50. Extremity Tank
  51. 51. Temperature Range <ul><li>Cold (32-79 0 F) </li></ul><ul><ul><li>Acute inflammation </li></ul></ul><ul><li>Tepid (79-92 0 F) </li></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Acute inflammation if cold not tolerated </li></ul></ul><ul><li>Neutral warmth (92-96 0 F) </li></ul><ul><ul><li>Open wound </li></ul></ul><ul><ul><li>Medically compromised patients </li></ul></ul><ul><ul><li>Decrease tone </li></ul></ul>
  52. 52. Temperature Range <ul><li>Mild warmth (96-98 0 ) </li></ul><ul><ul><li>Increase mobility </li></ul></ul><ul><ul><li>Burn </li></ul></ul><ul><li>Hot (99-104 0 ) </li></ul><ul><ul><li>Pain, </li></ul></ul><ul><ul><li>Increase ROM </li></ul></ul><ul><ul><li>Increase soft tissue extensibility </li></ul></ul><ul><li>Very Hot (104-110 0 ) </li></ul><ul><ul><li>Limited body area </li></ul></ul><ul><ul><li>Chronic conditions </li></ul></ul><ul><li>DO NOT use WP at temperatures > 110 0 F !! </li></ul>
  53. 53. Hubbard Tank <ul><li>8 feet long x 6 feet wide, 4 feet deep </li></ul><ul><li>425 gallons water </li></ul><ul><li>Turbines, stretcher, hoist </li></ul><ul><li>Expensive secondary to amount of water, time to clean </li></ul>
  54. 54. Contrast Bath <ul><li>Alternate immersion (distal) </li></ul><ul><ul><li>First warm/hot water, then cool/cold water </li></ul></ul><ul><li>Uses </li></ul><ul><ul><li>Decrease edema </li></ul></ul><ul><ul><li>Pain relief </li></ul></ul><ul><ul><li>Decrease sensitivity (desensitize) </li></ul></ul>
  55. 55. Application, Non-Immersion Irrigation <ul><li>PulsaVac: Lab </li></ul>
  56. 56. Application, Pool <ul><li>Temperature 79 - 97 0 </li></ul><ul><ul><li>Never below 65 0 </li></ul></ul><ul><ul><ul><li>Impairs muscles ability to contract </li></ul></ul></ul>
  57. 57. Cleaning, WP/Hubbard Tank <ul><li>Wear gloves, goggles, gown </li></ul><ul><li>Drain tank </li></ul><ul><li>Rinse with clean water </li></ul><ul><li>Scrub tank with brush and detergent and rinse again </li></ul><ul><li>Disinfect Tank </li></ul>
  58. 58. Disinfecting the Tank <ul><li>Levels of disinfection </li></ul><ul><ul><li>Low level </li></ul></ul><ul><ul><ul><li>Intact skin </li></ul></ul></ul><ul><ul><ul><li>70-90% ethyl alcohol, </li></ul></ul></ul><ul><ul><ul><li>sodium hypochloride bleach </li></ul></ul></ul><ul><ul><ul><li>germicidal solution </li></ul></ul></ul><ul><ul><li>Intermediate Level </li></ul></ul><ul><ul><ul><li>70-90% ethyl alcohol </li></ul></ul></ul><ul><ul><ul><li>phenolic germicidal detergent </li></ul></ul></ul><ul><ul><li>High Level </li></ul></ul><ul><ul><ul><li>Chlorine-based products </li></ul></ul></ul><ul><ul><ul><li>Can corrode tank </li></ul></ul></ul>
  59. 59. Disinfecting the Tank <ul><li>Change disinfectant periodically to decrease risk of resistant strains </li></ul><ul><li>Fill tank </li></ul><ul><li>Add solution ( hot water ) </li></ul><ul><ul><li>expose all inside surfaces x 10 minutes </li></ul></ul><ul><li>Clean and disinfect turbine, </li></ul><ul><ul><li>bucket with water/detergent x 5 minutes </li></ul></ul><ul><ul><li>bucket with disinfectant x 10 minutes </li></ul></ul>
  60. 60. Disinfecting the Tank <ul><li>Drain tank </li></ul><ul><li>Rinse with clean water </li></ul><ul><li>Dry thoroughly with towels </li></ul><ul><li>Culture tank, turbines, drains, and water supply periodically </li></ul>
  61. 61. Aquatic Exercise
  62. 62. Aquatic Exercise <ul><li>Uses </li></ul><ul><ul><li>Increase circulation </li></ul></ul><ul><ul><li>Increase muscle strength </li></ul></ul><ul><ul><li>Increase joint ROM, flexibility </li></ul></ul><ul><ul><li>Improve ambulation </li></ul></ul><ul><ul><li>Improve coordination </li></ul></ul><ul><ul><li>Increase cardiovascular, respiratory conditioning </li></ul></ul><ul><ul><li>Decrease pain, spasm </li></ul></ul><ul><ul><li>Decrease weight-bearing on joints </li></ul></ul><ul><ul><li>Relaxation/ psychological well-being </li></ul></ul>
  63. 63. Types of Aquatic Exercise <ul><li>Swimming </li></ul><ul><li>Running ( with or without vest ) </li></ul><ul><li>Walking </li></ul><ul><li>Cycling </li></ul><ul><li>Stretching </li></ul><ul><li>Underwater treadmill or parallel bars, etc. </li></ul>
  64. 68. The End